HIM 370 Exam 1 QUESTIONS AND ANSWERS

HIM 370 Exam 1 Who conducts research on the effectiveness of various methods of health care management, treatment, and financing; is reponsible for assessing the quality of health care facilities and services; and establishes reimbursement policies for providers? Correct Answer: CMS what did CMS do to increase scrutiny of improper payments by Medicare part A and B to hospitals? Correct Answer: Created RAC (recovery audit contractor) How far back can RAC go? Correct Answer: 3 years from date of discharge What did CMS develop and implement to focus on overpayments to providers/hospitals from Medicaid? Correct Answer: MIP (Medicaid Integrity Program) What did CMS do to indentify and investigate malicious fraud in 7 geographic locations? Correct Answer: created ZPIC (zone program integrity contractor) Who detects and corrects past and improper payments, can implement actions that will prevent future improper payments, and reviews claims on a post-payment basis Correct Answer: RAC What may providers request from RAC on findings? Correct Answer: education who does the responsibility of proper payments from medicaid lie with? Correct Answer: each state who is responsible for state oversight and accountability of Medicaid? Correct Answer: federal government who will check to make sure medicaid claims match what the plans have been reporting? Correct Answer: CMS What will CMS do to determine if the state beneficiaries are actually eligible? Correct Answer: initiate audits What will CMS do to reduce improper payments? Correct Answer: provide education Whose primary goal is to identify cases of suspected fraud development and take immediate action? Correct Answer: CMS Who ensures trust fund monies are paid out appropriately and recoups mistaken payments? Correct Answer: ZPIC (zone program integrity contractor) Who would ZPIC report fraud to? Correct Answer: OIG What happens if provider refuses to cooperate with ZPIC or is found to have committed malicious fraud with intent? Correct Answer: revocation of certification What does revocation of certification entail? Correct Answer: can not treat medicare and medicaid patients Whose job is the address patient outcomes and safety, improve quality of care provided, and serve to protect Medicare beneficiaries? Correct Answer: QIO Whose job is to serve and protect the Medicare trust fund, focus is on monthly data submissions, and ensure each provider has developed a clinical documentation improvement (CDI) plan? Correct Answer: QIO Whose job is to perform education to the doctors and nurses about documentation, perform monthly chart audits and abstract data which goes to a clearinghouse for compilation and compliance %, and evaluate provider against national/state/local average? Correct Answer: CDI department What are value based payment models tied to? Correct Answer: ACO (accountable care organizations) what payment model pays based on ability to meet pre-established quality and performance targets? Correct Answer: value based What are groups that work together to achieve higher quality outcomes/earn incentive payments? Correct Answer: ACO (accountable care organizations) Hospitals are required submit patient data monthly/quarterly to meet what? Correct Answer: HOP QDRP (hospital quarterly data reporting) What happens to hospitals that do not participate in IQR (inpatient quality report)? Correct Answer: reduced medicare payment rate what is the incentive reimbursement program for providers if they report quality measures for medicare beneficiaries? Correct Answer: PQRS (physician quality reporting system) what happens if providers do not participate in PQRS? Correct Answer: reduced medicare payment rate What was developed to improve quality of care by reimbursing based on clinical practices? Correct Answer: HVBP (hospital value based purchasing program) What happened if hospitals did not meet MU (meaningful use) standards by 2015? Correct Answer: financially penalized A shift in managed care to more quality outcome payments has yielded what? Correct Answer: decreased acute care admissions What are HIPAA covered entities? Correct Answer: Health care plans, clearinghouses, any provider that transmits PHI in an electronic form Who is licensure provided by? Correct Answer: state who is accreditation provided by? Correct Answer: TJC,CARF, AAAHC